A nurse on a hospice unit is caring for a client who has cancer and is in the active phase of dying. Which of the following findings requires intervention by the nurse?

Rationale for correct choices:

• Deep tendon reflexes 2+ bilaterally: DTRs decreased from 3+ to 2+, indicating reduced hyperreflexia. Hyperreflexia is a hallmark of preeclampsia and HELLP syndrome; improvement suggests that neuromuscular excitability and central nervous system irritability are stabilizing. Monitoring DTRs helps evaluate treatment effectiveness and risk reduction for complications.

• Oxygen saturation (SaO₂) 95% on 2 L nasal cannula: Oxygenation is within acceptable limits for a patient on supplemental oxygen. Maintaining adequate maternal oxygenation supports fetal perfusion and reduces hypoxic stress. Improved oxygen saturation reflects better respiratory status and cardiovascular stability compared with prior readings (SaO₂ 92–94%).

• Respiratory rate 18/min: The client’s respiratory rate is within normal limits, improving from earlier tachypnea (24/min). Stabilization of respiratory rate indicates reduced distress, better oxygenation, and improved overall maternal status, which contributes to safer outcomes for both mother and fetus.

• Blood pressure 146/96 mm Hg: At 1400, the client’s blood pressure had spiked to a very dangerous 170/112 mm Hg (severe hypertension). The decrease to 146/96 mm Hg by 1800 indicates that medical interventions are successfully lowering the pressure toward a safer range.

Rationale for incorrect choices:

• Temperature 38.3° C (101° F): The client’s temperature is elevated, indicating fever. Fever does not reflect improvement and may signal infection, inflammation, or other complications. Ongoing assessment and intervention are required to address the cause of hyperthermia.

• Urine output 40 mL: A single low urine output reading suggests oliguria, which is concerning in preeclampsia or HELLP syndrome. Adequate renal perfusion is essential; this value does not indicate improvement and requires ongoing monitoring.

• Heart rate 58/min: Bradycardia may be related to medications, vagal stimulation, or underlying cardiovascular changes. While it is a change from prior tachycardia, bradycardia itself is not an indicator of improvement and may require further evaluation.

A. Turn the client's head to the side: Turning the head to the side helps maintain airway patency and allows saliva or secretions to drain, reducing the risk of aspiration. This action is performed once the client is safely positioned and seizing. Airway protection is a priority during active seizure activity.

B. Guide the client to the floor: Safely guiding the client to the floor prevents injury from a fall during sudden loss of muscle control. This is the first priority when a seizure begins during ambulation. Protecting the client from trauma takes precedence over all other actions.

C. Provide supplemental oxygen: After the seizure activity subsides, oxygen may be needed to address hypoxia caused by impaired breathing during the seizure. Supplemental oxygen supports adequate tissue oxygenation during the postictal phase. This action follows airway positioning and stabilization.

D. Provide hygiene: Hygiene care is provided after the seizure once the client is stable, as incontinence or excessive secretions may have occurred. Maintaining cleanliness promotes comfort and dignity. This step is not urgent and is addressed after physiologic needs are met.

E. Initiate reorientation: Reorientation is performed last, during the postictal phase, when the client may be confused or disoriented. Calm reassurance and simple explanations help reduce anxiety and support neurologic recovery. This action is appropriate only once the client is alert and stable.